Provider Demographics
NPI:1255421897
Name:ORAL SURGERY LTD
Entity type:Organization
Organization Name:ORAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:RADDATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-248-8745
Mailing Address - Street 1:1277 E MISSOURI AVE
Mailing Address - Street 2:#110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2915
Mailing Address - Country:US
Mailing Address - Phone:602-248-8745
Mailing Address - Fax:602-248-7939
Practice Address - Street 1:1277 E MISSOURI AVE
Practice Address - Street 2:#110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2915
Practice Address - Country:US
Practice Address - Phone:602-248-8745
Practice Address - Fax:602-248-7939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT76846Medicare UPIN